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Director of Quality Improvement & Risk Management Saje Strategic Solutions San Fernando, CA Job Details Full-time $150,000

•$175,000 a year 6 hours ago Qualifications TJC CMS Hospital quality control Master's degree Acute care facility experience CMS regulatory compliance Hospital accreditation Bachelor's degree Regulatory readiness in healthcare Risk management leadership (healthcare) Quality assurance experience within healthcare Full Job Description SAJE Strategic Solutions is seeking an experienced Director of Quality Improvement & Risk Management to provide hospital-wide leadership for quality management, clinical performance improvement, risk mitigation, regulatory compliance, and survey readiness at a healthcare facility in the San Fernando Valley, CA . This senior leadership position will serve as a key administrative resource for quality and risk initiatives across acute medical services, behavioral health, and subacute care . The ideal candidate brings significant hospital quality leadership experience and extensive knowledge of CDPH, California Title 22, The Joint Commission (TJC), and CMS requirements .

Compensation & Position Details Salary:

$150,000

•$175,000+ annually , commensurate with experience

Position Type:

Full-Time Classification:

Exempt Location:

San Fernando Valley, CA Department:

Quality Improvement & Risk Management Reports To:

Chief Executive Officer /

Hospital Administrator Essential Duties & Responsibilities Quality Improvement & Risk Management:

Direct and evaluate hospital-wide Quality Improvement and Risk Management programs to ensure alignment with state licensing requirements and national accreditation standards.

Quality & Risk Planning:

Develop, revise, and implement annual written Quality Improvement and Risk Management plans that meet applicable statutory and accreditation requirements.

Incident & Risk Management:

Oversee incident reporting, sentinel event investigations, root-cause analyses (RCAs) , and development of corrective action plans (CAPs) .

Regulatory & Accreditation Leadership:

Maintain continuous survey readiness and compliance with: California Department of Public Health (CDPH) California Title 22 Centers for Medicare & Medicaid Services (CMS) The Joint Commission (TJC) Serve as a lead administrative liaison during unannounced state surveys, annual licensing audits, accreditation activities, and validation visits.

Medical Staff & Peer Review:

Partner with the Chief of Staff, medical department chairs, and attending physicians to facilitate clinical peer review and physician quality initiatives. Provide clinical data, case summaries, and variance analyses to medical staff committees and administrative leadership while assisting departments with corrective action plans related to clinical variances.

Quality Data & Analytics:

Direct the collection, aggregation, abstraction, and statistical presentation of hospital performance data, patient-safety indicators, and clinical outcomes.

Executive Reporting:

Prepare quality reports, dashboards, presentations, and meeting documentation for the Quality Committee, Medical Executive Committee (MEC), and Governing Board .

Authorization & Appeals Oversight:

Maintain oversight of authorization, denial, and appeal processes across acute care, behavioral health, and subacute settings. Qualifications & Requirements Education

•

REQUIRED

Bachelor's degree required. Advanced Education

•

PREFERRED

Master's degree in Public Health (MPH), Healthcare Administration (MHA), or Nursing (MSN) strongly preferred. Licensure /

Credentials:

Active California Registered Nurse (RN) license preferred , or an MPH, CPHRM, or CPHQ with equivalent clinical quality leadership experience. Hospital Experience

•

REQUIRED

Minimum 5 years of demonstrated hospital experience involving: Quality improvement Risk management Survey readiness Accreditation compliance

Healthcare System Experience:

Direct experience within a multidisciplinary healthcare system is preferred, particularly an acute hospital with subacute and/or psychiatric services .

Regulatory Expertise:

Extensive working knowledge of CDPH Title 22 and The Joint Commission survey processes . Key Skills & Core Competencies Hospital quality improvement leadership Risk management and incident investigation Regulatory and accreditation compliance CDPH and Title 22 expertise The Joint Commission survey readiness Root-cause analysis and corrective action planning Medical staff peer review Quality data analysis and reporting Strong statistical and analytical skills Executive-level presentation and communication Physician and medical staff engagement Ability to lead effectively during regulatory surveys and audits Ideal Candidate The ideal candidate is an accomplished healthcare quality leader with significant hospital-based Quality Improvement and Risk Management experience . You should be comfortable serving as a subject-matter expert for regulatory compliance, leading survey readiness efforts, managing complex quality and risk initiatives, partnering directly with physicians and executive leadership, and presenting quality data to senior hospital committees. Candidates with an active California RN license and hospital Quality/Risk leadership experience are particularly desirable; however, qualified candidates with an MPH, CPHRM, or CPHQ and equivalent clinical quality leadership experience may also be considered. If you have 5+ years of hospital Quality Improvement, Risk Management, survey readiness, and accreditation experience and are ready to take on a high-level leadership position, we encourage you to apply.

Pay:

$150,000.00

•$175,000.00 per year Application Question(s): Which of

RN/MPH/CPHRM/CPHQ

do you have? Do you have extensive working command of CDPH Title 22 and The Joint Commission survey processes; strong presentation, statistical analysis, and medical staff engagement skills?

Education:

Master's (Required)

Experience:

hospital

Quality & Risk Management:

5 years (Required) working within a multidisciplinary healthcare system: 1 year (Required)

License/Certification:

at least one of

RN/MPH/CPHRM/CPHQ

(Required)

Work Location:

In person